Sherlock Holmes: diagnosing breast cancer like a master sleuth

Diagnosing a breast cancer is the first step before treating one. This sounds easy in practise but is not as simple as it seems. Prof Carol-Ann Benn explains why, as well as all the different methods of diagnosis.

Historically the diagnosis of breast cancer was made when a woman presented with a mass in the breast, and a friendly surgeon cut the mass out with a variation on the theme of: “We will have a pathologist in theatre and if it is a cancer we will cut off your breast (like in Alice in Wonderland – off with her head!) 

This is not the way to do it. Not just in the wrongness of the surgeon cutting to find out the diagnosis; also in the lack of consent; having an anaesthetic, and signing or not signing for the removal of a body part. More so, there are some cancers that one should never start with an operation to diagnose as this jeopardises treatment success.

Diagnosing a breast cancer with a doctor doing a needle biopsy in the examination room is also foolhardy. 

The reason being is that if you stick a needle into the breast using just your fingers to direct you; this is flawed by the misconception that your fingers have eyes on them and can direct the direction and depth of the needle. This was usually followed by the results being inconclusive and the patient being told they need an operation to make the diagnosis.

Why check?

Our bodies are in constant flux. I often use the analogy of the African bushveld. By checking regularly, one picks up changes. The most important concept is listening to your body. We are all different; our bodies and our breasts. 

Some of us have breast tissue that is like wide-open savanna. Easy to see when an animal walks across the plains, be it a buck (a benign mass cyst or solid), or a predator (a cancer). For others, it’s a jungle out there. Dense scrub and hard to see anything, friend or foe. In fact, today the US radiology screening guidelines are adamant that the density (bush) needs to be documented and told to the patient. 

In other words, a disclaimer: we can’t see so clearly because your tissue is so dense. 

This is where the concept of hormones comes into play. Women in their 40s on oral contraceptives and women on HRT may have denser breasts. In that, the hormones fertilise the breast tissue, resulting in it being more difficult to see the predators (remember the hormones don’t cause the predators).

Types of breast radiology

So, fast-forward to the advent of breast radiology and breast cancer screening.

1. Mammography

This involves the use of X-rays to look into the breast tissue. Much has been written as to the harm of X-rays (radiation exposure) and that this can cause cancers. Whilst this may be true and mammograms many years ago (even before little old me started having mammograms) may have resulted in high doses of radiation to breast tissue. Today the radiation exposure from a mammogram is less than that received when walking through a shopping mall.  

How mammograms work?

Mammograms are a two-dimension view of a breast. There are two views taken: a CC view where the breast is squashed from top to bottom. Although this sounds painful, if done gently it’s not. Speak to the radiographer. A good radiographer who is experienced will not hurt you. The other view is: a MLO view. This is a view taken from the side. Both views ensure the best assessment of a breast from different angles. 

I often equate mammography as driving in the bush and looking from the side. This is why more people on the game vehicle may mean more success at spotting the predators. Add to that, this is why having a double read of your mammogram; or having it done in a unit that specialises in breast radiology is so important (specialist game ranger).

What mammograms pick up

Mammograms look for specific features, such as changes in density in different parts of the breast and spiculated masses (where a cancer causes the tissue to look like a scar). 

Calcifications are simply: skeletons of cells. Mammograms are good at seeing calcifications in the breast. There are different types of calcifications. 

One that looks like train tracks; these are called vascular calcifications and represent vessels. Interestingly, they can be a sign of vascular disease (check your heart and your cholesterol levels). 

If the calcifications are powdery and lie in an orderly formation, they can be benign (non-cancerous). If the calcifications lie in a certain formation, they can represent a cancer (looks like a shattered glass). 

Big calcifications that look like popcorn can be a sign of dying non-cancerous lumps, such as fibroadenomas; or of dead fat (fat necrosis).

Today, breakthroughs in breast mammograms include 3D mammography: breast tomosynthesis which is closer to a 3D look than a 2D.

2. Breast ultrasound

This method is like the binoculars: takes longer to scan the bush and is operator dependent. Breast ultrasound is best for assessing masses and seeing if they are solid or cystic, as well as assessing lymph nodes (glands). 

When you go for a mammogram, please ensure that the doctor does an ultrasound and always checks the lymph nodes in your armpit (axilla).

Breakthroughs in ultrasound include automated ultrasound (a possible screening tool) and elastography.

3. Breast MRI 

This is the helicopter scanning the bush from above. Obviously, this helicopter ride is more expensive. But, oh-so-good for looking at shadows and determining if they look like a sleeping predator.


Have you been on a game drive when the rangers talk in code? A “Tau” may mean a lion. Well, doctors have the same talk for radiology. This is the BIRADS system. So, in simple terms: if we call BIRADS 1 and 2, we mean it’s a non-threatening animal (a buck). If we call BIRADS 5 and 6, we have seen a predator. If we call BIRADS 4, we need to chase further…could well be a predator. If we call BIRADS 3 (my worst), we are so not sure. Just sitting on the fence; not really worried. Will drive past again later (come back in three months for an ultrasound). B3 does not sit well with an anxious ant like myself.

Fringe ways of assessing the breast

• Breast light

This is a light you shine on your breasts to see if you can see anything.

I have tried it on my fibroadenomas. I can best use the analogy of an electric tooth brush. It’s just a way to brush your teeth. More expensive. Maybe better at getting into the cracks. 

Though, at the end of the day, you can use a normal toothbrush (your hands) as long as you do a thorough job. So, I am not anti it, but it’s not the be-all and does not replace your mammogram and ultrasound.

• Thermography

Checking for heat signals in the breast. This comes with many false negatives and positives. You can choose to do this but it’s not a stand-alone, or a replacement for mammograms and ultrasounds.

• Four-legged friends

Let’s not forget our four-legged friends. There have been isolated case reports of dogs, in particular, detecting cancers by use of their superpower sense of smell.

Sherlock, how do you catch the villain? 

So, we’ve spotted something we don’t like, what now?

Core needle biopsy 

Thank goodness, we have Sherlock-style detectives! I am gifted with an amazing team (Simon and Chris; complimented by some kick-ass, spectacular female detectives: Lauren and Kirsty).

I am so not into shooting the predator to confirm it is what it is. Today, the elegance of pathology has ensured that we can take a small sample of a tumour and analyse it, to ensure best treatment. 

This is again where I get on my soapbox of ensuring that cancers are not cut out prior to assessing them. 

The gold standard of cancer diagnosis today is a core needle biopsy. This should always be done under radiology guidance, whether it be ultrasound, mammogram or MRI-guided.

A disclaimer: diagnosing breast cancer the correct way can be more expensive than some cowboy admitting you to hospital to cut out a concerning area.

Please ensure that no needle biopsy under radiology guidance is an emergency procedure.

Ask for a quote from the radiologist for the procedure. This usually goes off your savings, and then ask for a quote for the pathology. Note, these are two separate quotes.  

A biopsy can also be done at a government specialist breast clinic for a fraction of the price. 

Only once the biopsy is confirmed to be a proven cancer; you can be registered on an oncology plan. 

The secret is to be registered before a multitude of specialist stains are undertaken, by the detectives, to determine what kind of baddie we are dealing with. Remember, the personality of the cancer is critical (Read my previous articles: Luminal A , Luminal B, HER2 positive, Triple-negative, and lobular breast cancer.

Breast cancer is not an emergency 

Please do not rush into diagnosis techniques or treatment without ensuring that your case is discussed in a multi-disciplinary team environment. Be suspicious of doctors who insist that you must do this at speed and only recommend specific doctors. Do your research, it is after all your body.

Breast cancers that are hard to detect

Let’s end by demystifying those cancers that are hard to detect on mammograms and other radiology investigations. The Moriarty of radiology. Do you remember Sherlock’s nemesis?

1. Inflammatory breast cancer

This is a cancer that presents as a red hot inflamed breast. It can be so subtle, not in-your-face-red-or-hot, sometimes that vague heaviness and a pink tinge to the breast. 

This cancer may be missed at a radiology unit that is not looking for subtle signs: a vague thickening of the skin on the mammogram; an increase in the breast tissue density from one breast to another. 

A secret radiology tool is to use the ultrasound to check the lymph nodes. If they look concerning, biopsy a lymph node.

Inflammatory breast cancer, once diagnosed, should never be treated with an upfront mastectomy. All inflammatory cancers should be started on primary oncology treatment. This is a must. 

The cancer that revolutionised cancer care

Note, inflammatory breast cancer, was the cancer that revolutionised cancer care. In the 1950s, the surgeon was king. He wielded a big knife and ego, and was not scared. To cut was to cure. Unfortunately, when he cut the breast off in women with inflammatory breast cancers; the cancers rapidly returned. So, he decreed: “Send these women who are going to die anyway to the nerdy physicians.” 

They had five drugs and apologetically said death by drugs or cancer. This is why all oncologists are apologetic about side effects. As opposed to cardiologists who say take the drugs, or else you may have a heart attack or stroke. The truth is cancer kills and oncology has become quite designer (Louis Vuitton) and not one size fits all.

So, the survival rate of breast cancer has improved not due to surgical prowess but rather due to clever medicine. And, today many women with inflammatory breast cancer are alive for many years due to starting with primary oncology care. 

A small boast, our unit has a reconstructive specialist in inflammatory breast cancer, who has pioneered immediate reconstruction for a cancer that is traditionally treated by an ablative mastectomy.

2. Paget’s disease of the nipple 

This is a subtle nipple change that presents as a sort of itch and early abrasion on the top of the nipple. Unfortunately, Paget’s is often diagnosed late (average delay to diagnosis is 18 months) as the mammogram may not detect the subtle findings in the breast. 

Fifty percent of the time, an early Paget’s may have a sleeping cancer 

in the breast that is not seen on the mammogram. So, if you see a change on your nipple, please see a breast specialist and organise a punch biopsy of the nipple skin.

3. An unknown primary cancer 

The third Where’s Waldo? Moriarty of the breast world is the unknown primary cancer. This is Moriarty at his best. This is a patient who presents with a big lymph node, usually in the axilla. The mammogram shows no sign of cancer. The secret is not to cut out the lymph node; but to do a core biopsy of the lymph node, and handover the detective work to the clever Sherlocks and Watsons: the radiologists and the pathologists.

The radiologist (Watson) may suggest a breast MRI scan, or a whole-body MRI; a PET scan (not the four-legged version) to try and find Waldo. 

The pathologist (Sherlock) will do many special stains on the core biopsy to determine where the original site is. Terms like CK20 and Gata-3 will be bandied about.

Is this a breast cancer? A lymphoma? Metastases from another site? (Yes this happens) From the head and neck, from the skin, from the lung, from the gynae area, from the gastro-intestinal tract, etc? 

All this can be uncovered by the pathologist, so as to ensure that the cops, Scotland Yard, does its finest and rounds up the baddie with clever oncology care.

It’s elementary, my dear Watson

Let the clever docs do their thing before seeing the barber surgeons. Remember, long ago these were the surgeons. I am one, so please don’t take offence, and let Sherlock Holmes make the diagnosis and present them at the multi-disciplinary meeting.

Prof Carol-Ann Benn heads up an internationally accredited, multi-disciplinary breast cancer centre at Netcare Milpark Hospital. She lectures at Wits University and, in 2002, established the Breast Health Foundation.Prof Carol-Ann Benn heads up an internationally accredited, multi-disciplinary breast cancer centre at Netcare Milpark Hospital. She lectures at Wits University and, in 2002, established the Breast Health Foundation.

MEET OUR EXPERT – Prof Carol-Ann Benn

Prof Carol-Ann Benn heads up internationally accredited, multi-disciplinary breast cancer centres at Helen Joseph Hospital and Netcare Milpark Hospital. She lectures at Wits University and, in 2002, established the Breast Health Foundation.